Existing jobs at Missouri hospitals are hanging in the balance as state lawmakers wrestle with a decision over whether to expand Medicaid under the Affordable Care Act.

Gov. Jay Nixon visited Kirksville Thursday morning to discuss his plans and associated benefits of Missouri opting in to the expansion, saying it would create 24,000 jobs in 2014 alone, bring in $8.5 billion in federal money through 2019, and provide insurance to an estimated 300,000 Missourians.

Or, Missouri could choose not to expand Medicaid and, the governor noted, allow state tax dollars to go elsewhere.

While Republican lawmakers have largely balked at accepting a piece of Democratic President Barack Obama’s health care legislation, the ramifications of not expanding Medicaid go beyond political statements.

Failure to act allows two holes created by the ACA to remain open. From a health insurance standpoint, the ACA provides individuals with incomes of 100-138 percent of the poverty level subsidies to purchase private insurance, but has no such cost break for those below the 100-percent line ($11,170 per year).

The law was originally crafted to require Medicaid expansion, which would cover those individuals, but the Supreme Court’s ruling providing states an option opened a coverage gap.

“Without subsidy or relief, these people would remain uninsured,” said Thomas McAuliffe, policy analyst with the non-partisan Missouri Foundation for Health. “They could go to the [private health insurance] exchange, but not afford it.”

Many uninsured patients seek emergency medical care at hospitals, which by law are required to see them. Nixon said Thursday that hospitals across the state provide well over $1 billion in uncompensated care every year, a reality that helps drive health costs higher, while receiving a total of $256 million in Disproportionate Share Hospital payments to make up some of those losses.

But as part of the way the ACA is funded, those payments would be phased out and eventually eliminated. The law intended for most of those uninsured patients to be covered under Medicaid.

“If we fail to move forward on this [Medicaid expansion], we don’t stand still, we move back by $256 million,” Nixon said.

The Missouri Hospital Association, which supports the Medicaid expansion, paints a dire picture of a future where the state does not partake in the federal funds. It projects losses of more than 5,000 hospital jobs and 9,000 total jobs in the state through 2021, in addition to more than $1 billion in costs shifted to the insured.

Northeast Regional Medical Center CEO Eric Barber said the local hospital supports expanded Medicaid, adding the DSH payments bring in more than $680,000 annually to NRMC.

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“Our total payroll is over $20 million a year. Think about the amount of money we spend paying our employees, our physicians, our residents, paying the electric bills, all the things we do, there’s millions of dollars flowing out of our organization. We need every penny coming in,” Barber said. “I’d hate to think of us cutting jobs because we don’t have the money coming in the door.”

Scotland County Hospital CEO Marcia Dial said cuts could be devastating to small, rural hospitals.

“It would be significant and when you take significant dollars away from a hospital our size, then it means that we have to pare back on what we’re able to provide. It could cost jobs in our community,” she said.

Barber said he shared Nixon’s sentiment that politics should not be part of the discussion on Medicaid expansion.

“The appropriate reaction for the state of Missouri, to me, is obvious, and then you add in the families we see every day at Northeast Regional, who fit that category as [Gov. Nixon] so eloquently described. The working class, the people who are really trying to make ends meet, and are unfortunately in a situation where they can’t afford health care, or it’s not provided by their employer,” Barber said.

“There’s a gap in the health care system that’s been there for the entire 11 years I’ve been in health care administration. I’ve always been hopeful someone would find a way to fill that gap. Is this a perfect solution? Probably not. Is it a step in the right direction? Absolutely. I think it makes sense, and if you can help those folks who are trying to make ends meet and raise a family with three or four kids and make care more accessible to their families, make it more affordable, I say go for it.”